Exploring Clinical Practice Hours in Postbaccalaureate-to-Doctor of Nursing Practice Nurse Practitioner Programs

BACKGROUND

Advanced practice nursing education is evolving to the doctor of nursing practice (DNP) degree. The American Association of Colleges of Nursing (AACN) DNP Essentials required 1000 hours of direct patient care, whereas the Report of the National Task Force on Quality Nurse Practitioner Education (NTF) Criteria for Evaluation of Nurse Practitioner Programs required 500 direct patient care hours. Indirect hours were unclear and undefined. The AACN Essentials changed the 1000-hour requirement to 500 practice hours, and the NTF increased the direct patient care hours to 750.

PURPOSE

The study sought to describe the distribution of direct and indirect hours that the National Organization of Nurse Practitioner Faculties member schools offer in their seamless postbaccalaureate-to-DNP nurse practitioner (NP) program.

METHOD

A quantitative survey was distributed to schools of nursing.

RESULTS

Eighty-six surveys represented 86 distinct schools and 112 NP programs. Supervised direct patient care hours were an average of 791.31 hours. Indirect hours averaged 170.08 hours. The DNP project hours served as an indirect hour activity.

CONCLUSION

Many schools have more than 750 direct hours adhering to the 2022 NTF Standards. The indirect hour allocation varies and weighs heavily on the DNP project.

A study protocol for e-PainSupport: The use of a digital application for reporting pain and pain management in home hospice

High pain intensity is commonly experienced by patients with serious advanced illness. Impediments to improving pain intensity in home hospice include poor adherence to a pain management regimen due to caregivers' lack of knowledge and self-efficacy (confidence) in administering analgesics. e-PainSupport is a self-administered, digital application directly linked to patients' medical records. It has three elements: Education Module, Patient Pain Record, and the Pain Summary for Nurses. This study will test the effects of e-PainSupport on pain intensity when used by patients, caregivers, and nurses. The study's specific aims are as follows: Aim 1, compare the effects of e-PainSupport to a standard care condition, controlling for covariates (role [patient or caregiver], age, sex, ethnicity, education, and patient's diagnosis), on clinical improvement in pain intensity (primary outcome) and significant improvement on a pain intensity scale (secondary outcome); Aim 2, examine the mediating effects of patient and caregiver knowledge, self-efficacy, and adherence on change in pain intensity during 2 weeks, controlling for covariates and treatment condition; and Aim 3, identify nurses' perceptions of the use of e-PainSupport, including facilitators for and barriers to integration into agency workflow and benefits for patients. Participants (132 triads of patients, caregivers, and hospice nurses) will be recruited from Midwest hospice agencies. Patient and caregiver outcomes will be assessed at baseline and 2 weeks later. Data will be analyzed with multilevel modeling. Post-intervention, semi-structured interviews with nurses in the e-PainSupport condition will be analyzed using qualitative content analysis to identify perceived practice changes. e-PainSupport has the potential to facilitate nurse-patient communication and improve hospice patient pain management.

e-PainSupport: A Digital Pain Management Application for Home Hospice Care

e-PainSupport is a digital pain management application (app) designed to facilitate better pain management in hospice. Early testing revealed caregivers found it was easy to use and successful in communicating patient pain and caregiver administration of analgesics to hospice nurses. However, caregiver knowledge of analgesic management remained low. The purpose of this study was to enhance e-PainSupport by (a) adapting and integrating an evidence-based pain educational intervention; (b) increasing ease of accessing and navigating the app; and (c) facilitating app communication with agency electronic health records (EHRs). An advisory board method, including two key stakeholder groups (an expert panel and a caregiver advisory board), guided the adaptation of an evidence-based pain educational intervention. Further, stakeholders recommended format changes to increase app usability. Study staff worked with four hospice agencies to facilitate app communication with EHRs. While modification to the e-PainSupport app to integrate a pain educational intervention and facilitate usability was successful, EHR integration was challenging. Future evaluation is needed to evaluate the effects of e-PainSupport on pain intensity among home hospice patients.

Review of linear and nonlinear models in breath analysis by Cyranose 320

BACKGROUND

Analysis of volatile organic compounds (VOC) in breath specimens has potential for point of care (POC) screening due to ease of sample collection. While the electronic nose (e-nose) is a standard VOC measure across a wide range of industries, it has not been adopted for POC screening in healthcare. One limitation of the e-nose is the absence of mathematical models of data analysis that yield easily interpreted findings at POC. The purposes of this review were to (1) examine the sensitivity/specificity results from studies that analyzed breath smellprints using the Cyranose 320, a widely used commercial e-nose, and (2) determine whether linear or nonlinear mathematical models are superior for analyzing Cyranose 320 breath smellprints.
Methods: This systematic review was conducted according to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analyses using keywords related to e-nose and breath. 
Results: Twenty-two articles met the eligibility criteria. Two studies used a linear model while the rest used nonlinear models. The two studies that used a linear model had a smaller range for median of sensitivity and higher median (71% - 96%; Mdn = 83.5%) compared to the studies that used nonlinear models (46% - 100%; Mdn = 74%). Additionally, studies that used linear models had a smaller range for median of specificity but lower median (70% - 92%; Mdn = 81%) compared to studies that used nonlinear models (57% - 97%; Mdn = 83%).
Conclusions: Linear models achieved smaller ranges for medians of sensitivity and specificity compared to nonlinear models supporting additional investigations of their use for POC testing. Because our findings were derived from studies of heterogenous medical conditions, it is not known if they generalize to specific diagnoses.

Physical Activity in South Asian Indians: A Systematic Review of Randomized Controlled Trials

This review systematically examines the characteristics and effectiveness of randomized controlled trials with aerobic physical activity (PA) interventions tailored to South Asian Indians (SAIs). PubMed/MEDLINE, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar were searched. The search yielded 1,842 studies; 11 met the criteria. The Center for Evidence-Based Medicine's critical appraisal tool was used to assess the quality of studies. Studies that used supervised structured PA sessions, educational material in SAI languages, motivational strategies, and positive reinforcement for goal setting, reported significant improvement in PA (p < .05; Cohen's d ≤ 0.3 to >0.8). Future PA studies in India featuring SAIs would benefit from clinic-based one-on-one structured aerobic PA interventions. In contrast, SAI immigrants in Western countries would benefit from community-based structured aerobic PA interventions that are offered in groups and culturally adapted.

Perceptions of Caring Recruitment Among Older Adults: African Americans and Non-Latinx Whites

BACKGROUND

African Americans (AAs) are underrepresented in health-related research studies. Few studies have investigated how behaviors of study recruiters affect recruitment of older AAs versus non-Latinx Whites (NLWs).

OBJECTIVES

The aim of this study was to explore whether caring behaviors influence AA and NLW older adults' decision to participate in hypothetical, high-commitment, health-related research studies and differences in participants' enrollment decisions by race.

METHODS

Using a descriptive, cross-sectional study design, guided by Kristen Swanson's middle-range theory of caring, a research-savvy sample of 60 AA and 60 NLW adults (age > 65 years) were randomly assigned one of two written vignettes. The concept of caring behaviors was manipulated and illustrated in a hypothetical recruitment scenario. A participant feedback survey was used to assess (a) participants' perceptions of caring and uncaring behaviors exhibited by the fictitious research recruiter, (b) differences in their willingness to participate based on vignette type, and (c) participants' judgment of the research recruiter as being caring or uncaring. A chi-square test assessed the association among categorical variables (caring behavior and participants' race).

RESULTS

Participants who received the vignette with the high caring recruiter were more than twice as likely to agree to participate in the study than those who received the vignette with the low caring recruiter. AA and NLW participants did not differ in their likelihood to agree to participate. Participants who received the caring vignette and judged the recruiter as caring were 5 times as likely to agree to participate in the high-commitment study than those who received the uncaring vignette ( p < .001). Associations did not vary by race.

DISCUSSION

This experimental study of equally recruited older adults from an existing longitudinal study revealed that caring behaviors in recruitment strategies are associated with an increased likelihood of participation in high-commitment research with older adults. The research-savvy AA participants were just as likely to participate in the hypothetical high-commitment research as their NLW peers when the fictional research recruiter was perceived as having caring behaviors. When targeting specific populations, it is essential to employ nuanced recruitment approaches where the study recruiters are attuned to caring behaviors.

A Scoring Tool That Identifies the Need for Positive-Pressure Ventilation and Determines the Effectiveness of Allocated Respiratory Therapy

BACKGROUND

Hospital-acquired pneumonia (HAP) and the need for positive-pressure ventilation (PPV) are significant postoperative pulmonary complications (PPCs) that increase patients' lengths of stay, mortality, and costs. Current tools used to predict PPCs use nonmodifiable preoperative factors; thus, they cannot assess provided respiratory therapy effectiveness. The Respiratory Assessment and Allocation of Therapy (RAAT) tool was created to identify HAP and the need for PPV and assist in assigning respiratory therapies. This study aimed to assess the RAAT tool's reliability and validity and determine if allocated respiratory procedures based on scores prevented HAP and the need for PPV.

METHODS

Electronic medical record data for nonintubated surgical ICU subjects scored with the RAAT tool were pulled from July 1, 2015-January 31, 2016, using a consecutive sampling technique. Sensitivity, specificity, and jackknife analysis were generated based on total RAAT scores. A unit-weighted analysis and mean differences of consecutive RAAT scores were analyzed with RAAT total scores ≥ 10 and the need for PPV.

RESULTS

The first or second RAAT score of ≤ 5 (unlikely to receive PPV) and ≥ 10 (likely to receive PPV) provided a sensitivity of 0.833 and 0.783 and specificity of 0.761 and 0.804, respectively. Jackknifed sensitivity and specificity for identified cutoffs above were 0.800-0.917 and 0.775-0.739 for the first RAAT score and 0.667-0.889 and 0.815-0.79 for the second RAAT score. The initial RAAT scores of ≥ 10 predicted the need for PPV (P < .001) and was associated with higher in-hospital mortality (P < .001). Mean differences between consecutive RAAT scores revealed decreasing scores did not need PPV.

CONCLUSIONS

The RAAT scoring tool demonstrated an association with the need for PPV using modifiable factors and appears to provide a quantitative method of determining if allocated respiratory therapy is effective.

Using Vignette-Based Methodology to Examine Study Recruitment in Older African American Adults: A Methods Paper

This study's objective was to assess which caring recruitment behaviors correlate with the successful recruitment of older African-American adults-a two-step cross-sectional design employing a vignette-based survey methodology. Kristen Swanson's middle-range theory of caring was used to guide the examination of African-American adults' (65 years of age and older) perceptions of research-study-recruiter recruitment behaviors. This study's main findings are twofold: Step 1: Seven of ten invited experts identified major revisions of the two core vignettes, written at an eighth-grade reading level and high school comprehension. Step 2: A 51% response rate yielded findings that this methodology successfully captured older African-American adults' perception of research study recruiters' behavioral characteristics during the recruitment process. Older African-Americans who received the hypothetical caring vignette were twice as likely to indicate their willingness to enroll in a research study with a high commitment (i.e., brain donation) compared to their counterparts who received the hypothetical uncaring recruitment scenario. Vignette-based survey methodology holds promise as a tool for informing the recruitment of older African-American adults and other minorities into federally funded health-related research studies.

Insulin management in hospitalized patients with diabetes mellitus on high-dose glucocorticoids: Management of steroid-exacerbated hyperglycemia

Background

Glucocorticoid (GC)-exacerbated hyperglycemia is prevalent in hospitalized patients with diabetes mellitus (DM) but evidence-based insulin guidelines in inpatient settings are lacking.

Methods and findings

Retrospective cohort study with capillary blood glucose (CBG) readings and insulin use, dosed with 50% basal (glargine)-50% bolus (lispro) insulin, analyzed in hospitalized patients with insulin-treated DM given GC and matched controls without GC (n = 131 pairs). GC group (median daily prednisone-equivalent dose: 53.36 mg (IQR 30.00, 80.04)) had greatest CBG differences compared to controls at dinner (254±69 vs. 184±63 mg/dL, P<0.001) and bedtime (260±72 vs. 182±55 mg/dL, P<0.001). In GC group, dinner CBG was 30% higher than lunch (254±69 vs. 199±77 mg/dL, P<0.001) when similar lispro to controls given at lunch. Bedtime CBG not different from dinner when 20% more lispro given at dinner (0.12 units/kg (IQR 0.08, 0.17) vs. 0.10 units/kg (0.06, 0.14), P<0.01). Despite receiving more lispro, bedtime hypoglycemic events were lower in GC group (0.0% vs. 5.9%, P = 0.03).

Conclusions

Since equal bolus doses inadequately treat large dinner and bedtime GC-exacerbated glycemic excursions, initiating higher bolus insulin at lunch and dinner with additional enhanced GC-specific insulin supplemental scale may be needed as initial insulin doses in setting of high-dose GC.

Associations between sinus tachycardia and adverse cardiovascular outcomes and mortality in cancer patients

Background

Sinus tachycardia in cancer reflects a significant multi-system organ stressor and disease, with sparse literature describing its clinical significance. We assessed cardiovascular (CV) and mortality prognostic implications of sinus tachycardia in cancer patients.

Methods

We conducted a case-control study of 622 cancer patients at a U.S. urban medical center from 2008 to 2016. Cases had ECG-confirmed sinus tachycardia [heart rate (HR) ≥100 bpm] in ≥3 different clinic visits within 1 year of cancer diagnosis excluding a history of pulmonary embolism, thyroid dysfunction, left ventricular ejection fraction <50%, atrial fibrillation/flutter, HR >180 bpm. Adverse CV outcomes (ACVO) were heart failure with preserved ejection fraction (HFpEF), HF with reduced EF (HFrEF), hospital admissions for HF exacerbation (AHFE), acute coronary syndrome (ACS). Regression analyses were conducted to examine the effect of sinus tachycardia on overall ACVO and survival.

Results

There were 51 cases, age and sex-matched with 571 controls (mean age 70±10, 60.5% women, 76.4% Caucasian). In multivariate analysis over a 10-year follow-up period, sinus tachycardia (HR ≥100 vs. <100 bpm) was an independent predictor of overall ACVO (OR 2.8, 95% CI: 1.4–5.5; P=0.006). There was increased incidence of HFrEF (OR 3.3, 95% CI: 1.6–6.5; P=0.004) and AHFE (OR 6.3, 95% CI: 1.6–28; P=0.023), but not HFpEF or ACS (P>0.05) compared with controls. Sinus tachycardia was a significant predictor of overall mortality after adjusting for significant covariates (HR 2.9, 95% CI 1.8–5; P<0.001).

Conclusions

Independent of typical factors that affect cardiovascular disease, sinus tachycardia around the time of cancer treatment is associated with increased ACVO and mortality in cancer patients at 10 years of follow-up.

Neurocognitive Outcomes from Memantine: A Pilot, Double-Blind, Placebo-Controlled Trial in Children with Autism Spectrum Disorder

Objective: Studies interrogating therapeutics which alter the excitation-inhibition balance in the treatment of autism spectrum disorder (ASD) have reported mixed results on social and behavioral outcomes. Methods: The aim of this randomized, double-blind placebo-controlled pilot trial was to evaluate neurocognitive effects of memantine over a 24-week trial. Twenty-three children ages 6-12 years old with ASD were randomized to memantine or placebo. Primary outcomes included measures of apraxia and expressive language with evaluations at midpoint (week 12) and endpoint (week 24). Secondary outcomes included memory and adaptive behavior measures. Exploratory outcomes included changes in overall cognitive functioning and behavior (e.g., Aberrant Behavior Checklist). Results: Results suggest that memantine was well-tolerated. Dropout rates were high across groups with only 14 participants completing the 6-month trial. Memantine was not associated with improvements in apraxia and expressive language. Treatment with memantine was associated with improvements in verbal recognition memory as measured by the Narrative Memory-Recognition (NEPSY-II) (F = 5.05, p = .03). In addition, exploratory analyses of changes in Intelligence quotient (IQ) suggest improvements on verbal IQ (d = 1.8). Conclusions: Results suggest future studies of memantine in ASD may benefit from shifting treatment targets from social and behavioral outcomes to exploration of effects of memantine on cognition, potentially as an adjunct to learning and educational interventions. ClinicalTrials.gov: NCT01372449.

Health Care Utilization Patterns of Patients With Intellectual and Developmental Disabilities in the Acute-Care Setting

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.

This study describes adults with intellectual and developmental disabilities (IDD) in the acute-care hospital setting and identifies differences in their experience compared with those of patients without IDD. Comparative analysis between the two samples revealed differences in the length of stay, insurance provider, discharge environment, and number of OT visits per day. This study affects the field of OT by increasing awareness of the utilization patterns of health care services for patients with IDD.

Primary Author and Speaker: Samantha Conrad

Additional Authors and Speakers: Molly Bathje, Matthew Medick, and Molly Ross

Contributing Authors: Louis Fogg

Renal Forniceal Rupture in the Setting of Obstructing Ureteral Stones: An Analysis of Stone Characterization and Urologic Intervention Pattern

Introduction and Objective: Forniceal rupture due to obstructing ureterolithiasis (FROU) is a seldom encountered radiographic finding, but the impact of this diagnosis and influence on stone management has not been well studied in the literature. The purpose of the study is to examine stone characteristics and intervention patterns of patients with radiographic evidence of FROU. Materials and Methods: A retrospective analysis of all patients with radiographic evidence of FROU was compared with patients with obstructing ureteral stones without forniceal ruptures (noFROU). All patients presented to our Emergency Department from January 2015 until December 2018. Data analyzed included patient demographics, clinical presentation, stone characteristics, and management pattern. Primary outcome was need for hospital admission and surgical intervention. Results: Thirty-two patients with FROU (mean age = 45) were compared with 50 patients with noFROU (mean age = 57). Univariate analysis revealed that age, history of diabetes mellitus, history of hypertension, days of symptoms, degree of hydronephrosis, and degree of perinephric stranding were associated with forniceal rupture (p ≤ 0.05). On multivariate analysis, only degree of perinephric stranding remained significant (p ≤ 0.05). Average maximum axial stone diameter in the FROU group was 5.1 mm vs 4.7 mm in the noFROU group (p = 0.66). Overall, 68.8% of stones were located within the distal ureter in the FROU group vs 48.8% in the noFROU group (p = 0.09). There was no difference in hospital admission (FROU 37.5% vs noFROU 44%, p = 0.56) and need for surgical intervention (FROU 50% vs noFROU 48%, p = 0.86). There were no 30-day complications in patients with FROU. Conclusions: Ureteral stone location and size does not seem to impact the presence of FROU. FROU may be an alarming reported finding but its presence does not appear to impact clinical outcomes or affect urological management, including admission or need for urologic intervention.

Bilateral motor priming for post stroke upper extremity hemiparesis: A randomized pilot study

BACKGROUND

Bilateral priming, device assisted bilateral symmetrical wrist flexion/extension, is a noninvasive neuromodulation technique that can be used in the clinic.

OBJECTIVE

We examined the additive effect of bilateral motor priming and task specific training in individuals with severe upper limb hemiparesis.

METHODS

This is a parallel assignment, single-masked, randomized exploratory pilot study with three timepoints (pre-/post-intervention and follow up). Participants received either bilateral motor priming or health care education followed by task specific training. Sixteen participants who were at least 6 months post-stroke and had a Fugl Meyer Upper Extremity (FMUE) score between 23 and 38 were randomized. Our primary and secondary measures were Chedoke Arm & Hand Activity Index 9 (CAHAI-9) and the FMUE respectively. We determined changes in interhemispheric inhibition using transcranial magnetic stimulation. We hypothesized that improvement in the priming group would persist at follow up.

RESULTS

There was no between-group difference in the CAHAI. The improvement in the FMUE was significantly greater in the experimental group at follow up (t = 2.241, p = 0.045).

CONCLUSIONS

Both groups improved in the CAHAI. There was a significant between-group difference in the secondary outcome measure (FMUE) where the bilateral priming group had an average increase of 10 points from pre-intervention to follow up.

An interdisciplinary approach to safe opioid prescribing and administration for surgical patients at an academic medical center

AIM AND OBJECTIVES

To explore and understand the current practice, perceptions, and knowledge of general surgery trainees, advanced practice providers, and surgical nurses regarding opioid prescribing and administration. To this end, a novel opioid education and training was introduced to educate these practitioners on safe opioid practices in surgical patients.

BACKGROUND

National awareness of the opioid epidemic has increased significantly in the last several years. However, there remain a disturbingly high number of opioid prescriptions written in the US indicating a need for improved provider and nurse education. This involves increasing awareness and understanding of national guidelines as well as implementing multi-modal therapy to treat pain.

DESIGN

Pre-post-intervention quality improvement project.

METHODS

An opioid education and training involving a morphine equivalent daily dosing calculator in the electronic medical record was provided to 26 surgical trainees, eight advanced practice providers and 97 surgical nurses in November 2019. Perceptions, current practice and knowledge were measured using a pre- and post-intervention survey (SQUIRE checklist).

RESULTS

The survey results showed a positive clinical change in perception of opioid use in surgical patients following the intervention and a modest decrease in the average morphine equivalent daily dosing at discharge in general and transplant surgery patients.

CONCLUSIONS

Effective pain management for surgical patients must be individualised. Safe opioid prescribing should involve an interdisciplinary approach with all members of the team undergoing assessment of their opioid knowledge and prescribing habits, easily accessible training tools and opioid calculators in the electronic medical record.

RELEVANCE TO CLINICAL PRACTICE

Our initiative may provide useful information to settings that replicate use of a morphine equivalent daily dosing calculator in the electronic medical record. Utilisation of safe opioid prescribing tools in the electronic medical record and continuing education for providers and nurses can help ensure the safety of surgical patients.

Disrupted diurnal oscillation of gut-derived Short chain fatty acids in shift workers drinking alcohol: Possible mechanism for loss of resiliency of intestinal barrier in disrupted circadian host

Microbiota derived short chain fatty acids (SCFAs) are produced by fermentation of nondigestible fiber, and are a key component in intestinal barrier homeostasis. Since the microbiome has diurnal fluctuations, we hypothesized that SCFAs in humans have a diurnal rhythm and their rhythmicity would be impacted by the host central circadian misalignment (night shift work) which would make intestinal barrier more susceptible to disruption by alcohol. To test this hypothesis, we studied 3 groups of subjects: patients with alcohol use disorder, but no liver disease (AD), healthy day workers (DW), and night workers (NW). All subjects were studied at baseline and then in DW and NW subjects after moderate daily alcohol (0.5 g/kg) for 7 days. Gut-derived plasma SCFAs showed a significant circadian oscillation by cosinor analysis in DW; however, SCFA in the AD and NW subjects lost 24-hour rhythmicity. Decrease in SCFA correlated with increased colonic permeability. Both chronic and moderate alcohol consumption for 1 week caused circadian disruption based on wrist actigraphy and urinary melatonin. Our study shows that (1) gut-derived plasma SCFAs have a diurnal rhythm in humans that is impacted by the central clock of the host; (2) moderate alcohol suppresses SCFAs which was associated with increased colonic permeability; and (3) less invasive urinary 6-SM correlated and rest-activity actigraphy correlated with plasma melatonin. Future studies are needed to examine the role circadian misalignment on gut derived SCFAs as possible mechanism for loss of intestinal barrier resiliency to injurious agents like alcohol.

Examination and Analysis of After-Hours Calls in Hospice

To ensure safe and effective care at home, most hospice agencies provide 24-hour call services to patients and their families. However, responding to such calls can be very extensive since so many calls occur after hours when staff are fewer. The purpose of the current study was to better understand the types of after-hours calls and differences across patient teams. By understanding why these calls are made, we might be able to reduce the number of avoidable after-hours calls. This descriptive retrospective chart review study was conducted using data from 9 patient care teams within a single hospice agency. During the 6-month study period, the hospice agency received 1596 after-hours calls. The number of calls averaged 10.3 per night. Common clinical-related calls included consultations about the shortness of breath (10.2%) and pain (9.5%). A total of 37.7% of the calls were nonclinical, nonemergency in nature, including requests for supplies (29.6%) and medication refills (8.1%). There were statistically significant differences (P < .05) between teams in the numbers of supply request calls, medication refill request calls, and calls associated with clinical-related issues. Also, there was a statistically significant difference in the after-hours calls across teams that resulted in dispatching staff to a home (P < .05). These findings suggest that many after-hours calls would be more appropriately addressed during regular daytime hours. There are significant across-team differences that are not yet well understood. Further studies are needed to determine how to reduce the number of after-hours calls.

Image-Based Markers Predict Dynamic Instability in Lumbar Degenerative Spondylolisthesis

Objective

To identify possible radiographic predictors markers of dynamic instability including disc height (DH), disc degeneration, and spondylosis in the setting of degenerative spondylolisthesis (DS).

Methods

A retrospective review with prospectively collected data was performed on 125 patients with L4–5 DS who underwent decompression and fusion. Patients were divided into groups with dynamic instability and those without. Radiographs of the lumbar spine in neutral, flexion, and extension were used to determine degree of slip, DH, translational motion, angular motion, spondylotic changes, and lumbar lordosis. Magnetic resonance imaging (MRI) scans were reviewed to assess disc degeneration.

Results

Thirty-one percent of the patients met criteria for dynamic instability. Significant correlations (p < 0.05) were found between preserved DH and dynamic instability; increased spondylotic changes and decreased translational motion; as well as advanced MRI-based disc degeneration scores with decreased angular motion, respectively. Six radiographic parameters were utilized to create a predictive model for dynamic instability, and a receiver operating characteristic curve was able to validate the predictive model (area = 0.891, standard error = 0.034, p < 0.001).

Conclusion

In DS patients, preserved DH was significantly related to dynamic instability. This finding may represent a greater potential for slip progression over time in these patients. In contrast, disc degeneration on MRI, and spondylotic changes were inversely related to dynamic instability and may represent restabilization mechanisms that decrease the chance of future slip progression in DS.

Ensuring accurate BP measurements

Accurate BP measurements are vital for determining appropriate medication and treatment regimens. This article describes a quality improvement project to increase compliance with the American Heart Association's guidelines for BP measurement.

Teen pregnancy in Chicago: Who is at risk?

BACKGROUND

Teenage pregnancy, with its associated health and social consequences for young people and society as a whole, is one of the nation's most important public health issues. The purpose of this study was to use Youth Risk Behavior Survey (YRBS) data describe self-reported, pregnancy experiences in 9-12th grade Chicago Public Schools (CPS) students and identify teens at highest risk based on gender, grade-level, race, ethnicity, and sexual orientation.

METHODS

Secondary data analysis of the 2017 CPS high school Youth Risk Behavior Survey was conducted.

RESULTS

The survey response rate was 73% (n = 1,883). 4.9% (n = 91) of CPS students in grades 9 - 12 reported a pregnancy experience, and 1.9% (n = 34) reported being "unsure" of a pregnancy experience. Statistically significant differences in the likelihood of self-reporting a pregnancy experience were found based on grade level (p = .000), race (p = .023), and sexual orientation (p = .000).

CONCLUSION

While risk for a teen pregnancy experience varies across all groups, public health nurses can use YRBS data to better understand pregnancy risk in the populations they serve and can leverage core competencies, and robust community relationships to adapt, implement and evaluate evidence-based teen pregnancy prevention programs for maximum impact on teens at greatest risk.

Abstract P5-06-24: Validation of the Johns Hopkins oncotype DX recurrence score estimator

Objective

Oncotype DX (ODX) is a 21-gene assay used to predict the benefit of adjuvant chemotherapy in hormone receptor-positive, HER2-negative, lymph node-negative breast cancer. However, the test is expensive and the incremental contribution of this assay to routinely available clinicopathological information and how to integrate that information to best inform clinical decision making is unknown. Several models have been developed to predict whether there are cases in which a clinician or patient could opt to forgo ODX because the outcome of the test might be predicted with a high degree of accuracy using routinely available measures. One such model was developed and validated at Johns Hopkins University. Here we used their recurrence score estimator to learn whether we could safely adopt the calculator for use at our institution to improve resource utilization.

Methods

An IRB-approved prospective database was created in 2010 for patients seen by a single medical oncologist at Rush University Medical Center and for whom oncotype DX was performed. From this database, patients were identified with HR+, HER2-negative, node-negative breast cancer and for whom age at diagnosis, tumor size, grade and Ki-67 were known. These data were entered into the Johns Hopkins breast cancer recurrence score estimator (http://www.breastrecurrenceestimator.onc.jhmi.edu). This model categorizes patients with a recurrence score (RS) of less than or equal to 25 as low risk and those with a score of greater than 25 as high risk.

Results

There were 189 patients. The mean age, tumor size, ER%, PR% and Ki-67% were 58 years old, 1.5 cm, 88%, 44% and 15% respectively. 14% had a RS greater than 25. The estimator assigned 65 patients to low risk, 59 of whom had a low RS and 6 with a high RS. The estimator assigned 4 patients to high risk, all of whom had a high RS.

Conclusions

The Johns Hopkins recurrence score estimator assigned 69 patients to low or high risk with 91.3% accuracy. Future analysis of a larger sample size is needed to optimize the accuracy of this estimator nationally. It may also be beneficial to separately analyze patients aged 50 or younger with an ODX score between 16 and 25 who had chemotherapy benefit in the TAILORx study in order to improve the utility of this risk estimator.

Citation Format: Kristen Millado, Louis Fogg, Ritu Ghai, Melody Cobleigh. Validation of the Johns Hopkins oncotype DX recurrence score estimator [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-06-24.

Understanding Student Preferences in the Selection of a Graduate Allied Health Program: A Conjoint Analysis Study

ISSUE

As the healthcare landscape rapidly changes, graduate allied health programs must position themselves to educate the next generation of healthcare professionals in a highly competitive landscape. No studies have directly measured the relative importance of attributes in program selection by prospective healthcare students.

METHODS

We surveyed graduate healthcare management program applicants in the 2018 admissions cycle (n=512) to determine which attributes were most important in program choice. We utilized conjoint analysis to estimate utilities and importance scores of six attributes: program ranking, cost, work experience, geography, distance to home, and salary. We then conducted a market simulation to predict relative market share of academic programs.

OUTCOMES

The most important attribute to prospective students was the projected starting salary, with US News and World Report ranking and tuition cost the second and third most important attributes, respectively. Each attribute was relatively inelastic respective to tuition cost.

CONCLUSION

While future leaders placed the most value on earnings when selecting a program, they also valued rankings and cost. By focusing on these factors, programs can target their marketing efforts to recruit the best potential future healthcare leaders, while this method can be replicated to gauge the most important relative attributes for a variety of healthcare professions.

Electronic Nose Analysis of Exhaled Breath Volatiles to Identify Lung Cancer Cases: A Systematic Review

The purpose of our review was to analyze evidence of the validity of electronic noses to discriminate persons with lung cancer from healthy control subjects and to advance implications for this technology in the care of people living with HIV. A computerized database search of the literature (published 1946-2018) was conducted to identify studies that used electronic nose-generated smellprints to discriminate persons with lung cancer from healthy control subjects. Fifteen articles met the sampling criteria. In 14 studies, mean sensitivity and specificity values from a single training sample were 84.1% and 80.9%, respectively. Five studies applied the prediction model obtained from the training sample to a separate validation sample; mean sensitivity was 88.2%, and mean specificity was 70.2%. Findings suggest that breath smellprints are valid markers of lung cancer and may be useful screening measures for cancer. No studies included people living with HIV; additional studies are needed to assess generalizability to this population.

Evaluation of an Interview Process for Admission into an Occupational Therapy Program

Graduate school admissions interviews serve multiple purposes. Interviews allow applicants to promote non-cognitive attributes that may not have translated from other admissions materials. Additionally, the interview is often cited as a way for programs to assess the 'suitability' of an applicant. Evidence related to psychometric properties for graduate admissions interview processes is inconsistent. This study analyzes the psychometric properties of a specific group interview process for admission into an occupational therapy program. Retrospective data were used to assess interrater reliability using an intraclass correlation. Current students were invited to complete the RAND Social Health Battery to correlate with interview scores, two measures of social participation, to examine predictive validity. Results show a strong correlation between specific interviewers. A one-way ANOVA showed significant differences between individual interviewers. No significant correlation between interview scores and the RAND Social Health Battery was found. Results indicate that although inter-rater reliability was established, a closer look reveals individual differences between raters. The validity of the group interview, based on social participation, was not supported. Given the influence of the interview on admission processes, authors recommend programs complete in-depth evaluation of inter-rater reliability and identify and measure constructs intended to be captured in the interview.

Influence of breast reconstruction on technical aspects of echocardiographic image acquisition compared with physician-assessed image quality

Introduction

Assessment of cardiac function after treatment for breast cancer relies on interval evaluation of ventricular function through echocardiography. Women who undergo mastectomy more frequently choose to undergo breast reconstruction with implant. This could impede assessment of cardiac function in those with left-sided implant. We aimed to examine whether left-sided breast reconstruction with tissue expanders (TE) affect echo image acquisition and quality, possibly affecting clinical decision-making.

Methods

A retrospective case-control study was conducted in 190 female breast cancer patients who had undergone breast reconstruction with TE at an urban academic center. Echocardiographic technical assessment and image quality were respectively classified as excellent/good or adequate/technically difficult by technicians; and excellent/good or adequate/poor by 2 board-certified cardiologist readers. Likelihood ratio was used to test multivariate associations between image quality and left-sided TE.

Results

We identified 32 women (81.3% white; mean age 48 years) with left-sided/bilateral TE, and 158 right-sided/no TE (76.6% white, mean age 57 years). In multivariable analyses, we found a statistically significant difference in technician-assessed difficulty in image acquisition between cases and controls (p = 0.01); but no differences in physician-assessed image quality between cases and controls (p = 0.09, Pearson’s r = 0.467).

Conclusions

Left-sided breast TE appears to affect the technical difficulty of echo image acquisition, but not physician-assessed echo image quality. This likely means that echo technicians absorb most of the impediments associated with imaging patients with breast TE such that the presence of TE has no bearing on downstream clinical decision-making associated with echo image quality.

FAMILY DEMENTIA CAREGIVER RECRUITMENT STRATEGIES IN LONG-TERM CARE FACILITIES

Recruitment of dementia caregivers whose family members reside in long-term care facilities (LTCFs) poses unique challenges as it traditionally relies on the assistance of facility administrators. The purpose of this presentation is to examine and evaluate new recruitment strategies to determine their effectiveness in an ongoing Stage I randomized clinical trial testing the effects of a Chronic Grief Management Intervention, Video-streamed (CGMI-V) on caregivers’ mental health (grief, depression, anxiety) and facility-related outcomes (conflict with staff, satisfaction with care). A total of 144 caregivers will be randomly assigned to the CGMI-V or to the minimal treatment conditions. The initial recruitment plan was to build on already-established relationships with more than 35 LTCFs that helped recruit in a previous study. The usual approach was to offer written materials and onsite presentations about the study to facility staff and to dementia family caregivers of facility residents. Within the first six months, recruitment efforts yielded less than a dozen participants, thus we had to refine our approach. Revised recruitment strategies included the adoption of resources from the National Institute on Aging’s ADORE (Alzheimer’s and Dementia Outreach, Recruitment, and Engagement) and ROAR (Recruiting Older Adults into Research) platforms. This new approach included online study advertising on NIH and Alzheimer’s Association research study repositories and advertising on parent institution’s on-hold messaging system. Adoption of these new strategies is yielding an increase in participant screening and enrollment. Results are pending.

2849. Gut Microbiota Differences at the Time of Medical Intensive Care Unit (MICU) Admission Are Associated with Acquisition of Multi-drug-Resistant Organisms (MDROs) Among Patients Not Already Colonized with an MDRO

Background

Among hospitalized patients, underlying variation in gut microbiota may confer differential risk for gut MDRO acquisition.

Methods

Rectal swab samples were collected from patients ≤2 days of MICU admission and then daily in the 27-bed MICU of an acute care hospital in Chicago, IL over 1 year. Patients were screened for MDRO colonization by selective culture (see Figure 1 for MDRO types); those with ≥2 swabs and MICU stays ≥3 days were studied. Bacterial 16S rRNA gene amplicon sequences were used for microbiota analysis. Medical records were reviewed.

Results

In preliminary analysis, 2,480 samples were collected from 627 patients who acquired 170 MDROs (Figure 1). Debilitation, co-morbidities, and certain medical devices were associated with MDRO acquisition, though admission MDRO status was not (table). While no interactions were detected between admission MDRO status and clinical predictors of MDRO acquisition, there were significant differences in gut microbiota composition at the time of MICU admission between patients colonized with an MDRO on admission and those not colonized (P < 0.001, using analysis of molecular variance (AMOVA) on distances). Therefore, we stratified our analysis by admission MDRO colonization status. For patients MDRO-colonized at admission, there were no significant differences in microbiota of patients who later did or did not acquire a new MDRO (AMOVA P-value = 0.32). For patients not MDRO-colonized on admission, there was a significant difference in microbiota of patients who later acquired an MDRO and those who did not (AMOVA P-value: 0.026). Differentially abundant operational taxonomic units (OTUs, based on 3% sequence difference) included OTUs classified as Anaerococcus and as other Clostridiales (higher in patients who remained uncolonized) and as Enterococcus (higher in patients who acquired an MDRO) (Figure 2). Diversity was also higher in patients who remained uncolonized (Wilcoxon test P-value: 0.035) (Figure 3).

Conclusion

Among patients not already colonized with an MDRO on admission, we identified gut microbiota differences associated with MDRO acquisition that could help explain patient-level variation in MDRO colonization resistance.

Disclosures

All Authors: No reported Disclosures.

Satisfaction, safety, and supports: Comparing people with disabilities' insider experiences about participation in institutional and community living

BACKGROUND

Legislation and court decisions in the United States mandate the right to least restrictive community living and participation for people with disabilities, yet little research has examined differences in participation across institutional and community settings, or over time in the community post-transition.

OBJECTIVE

As part of a multi-site participatory action research project examining participation, we examined the differences in quality of life in institutional and community living environments among people with disabilities.

METHODS

We conducted surveys with adults with disabilities between 18 and 65 years-old that transitioned from institutions to the community in the United States within the last five years. This paper reports on findings for a diverse sample of 150 participants.

RESULTS

We found significant differences between ratings of institutional and community experiences, with increased reports of satisfaction, personal safety, service access, and participation in community settings. We also found significant improvements in community integration and inclusion after transition to community living, although barriers to transportation and activity access often remained.

CONCLUSIONS

This study of insider experiences of previously institutionalized people with disabilities illuminates important understandings of community participation, integration, and quality of life for the disability community in the United States.

Increased Relative Abundance of Klebsiella pneumoniae Carbapenemase-producing Klebsiella pneumoniae Within the Gut Microbiota Is Associated With Risk of Bloodstream Infection in Long-term Acute Care Hospital Patients

BACKGROUND

An association between increased relative abundance of specific bacterial taxa in the intestinal microbiota and bacteremia has been reported in some high-risk patient populations.

METHODS

We collected weekly rectal swab samples from patients at 1 long-term acute care hospital (LTACH) in Chicago from May 2015 to May 2016. Samples positive for Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) by polymerase chain reaction and culture underwent 16S rRNA gene sequence analysis; relative abundance of the operational taxonomic unit containing KPC-Kp was determined. Receiver operator characteristic (ROC) curves were constructed using results from the sample with highest relative abundance of KPC-Kp from each patient admission, excluding samples collected after KPC-Kp bacteremia. Cox regression analysis was performed to evaluate risk factors associated with time to achieve KPC-Kp relative abundance thresholds calculated by ROC curve analysis.

RESULTS

We collected 2319 samples from 562 admissions (506 patients); KPC-Kp colonization was detected in 255 (45.4%) admissions and KPC-Kp bacteremia in 11 (4.3%). A relative abundance cutoff of 22% predicted KPC-Kp bacteremia with sensitivity 73%, specificity 72%, and relative risk 4.2 (P = .01). In a multivariable Cox regression model adjusted for age, Charlson comorbidity index, and medical devices, carbapenem receipt was associated with achieving the 22% relative abundance threshold (P = .044).

CONCLUSION

Carbapenem receipt was associated with increased hazard for high relative abundance of KPC-Kp in the gut microbiota. Increased relative abundance of KPC-Kp was associated with KPC-Kp bacteremia. Whether bacteremia arose directly from bacterial translocation or indirectly from skin contamination followed by bloodstream invasion remains to be determined.

Improving Stage of Change in an Employee Wellness Program

Physical activity readiness of front-line employees caring for adults with disabilities (N = 381) improved during a two-phase project based on stages of change (SOC) theory. In Phase 1, we assessed barriers to, and readiness for, participation in an employee wellness program. We collected data from workers using focus groups and a preintervention physical activity readiness survey. Focus groups (N = 14) identified barriers, including lack of communication about the employee wellness program. With respect to their SOC (N = 82), 7% were in precontemplation, 16% in contemplation, 52% preparation, 5% in action, and 20% in maintenance SOC. In Phase 2, we aimed to improve readiness for participation in the program. We used SOC-based employee Facebook group messages, a health education fair, and measurement through a postintervention physical activity readiness survey. The mean number of "views" in which the workers saw the 16 theory-based messages was 12.2 (range = 0-27). Fourteen adults and 17 children attended the fair. Postintervention survey results (N = 125) indicated physical activity readiness improvement with 1% in precontemplation, 21% in contemplation, 33% in preparation, 33% in action, and 12% in maintenance SOC.

Attention in Bilingual Children With Developmental Language Disorder

Purpose Attention and language are hypothesized to interact in bilingual children and in children with developmental language disorder (DLD). In children who are bilingual, attentional control may be enhanced by repeated experience regulating 2 languages. In children with DLD, subtle weaknesses in sustained attention may relate to impaired language processing. This study measured attentional control and sustained attention in monolingual and bilingual children with and without DLD in order to examine the potential influences of bilingualism and DLD, as well as their intersection, on attention. Method Monolingual English-only and bilingual Spanish-English children aged 6-8 years were categorized into participant groups based on eligibility testing and parent interviews. Parent interviews included standardized assessment of language environment and parent concern regarding language. Participants completed 2 nonlinguistic computerized assessments: a flanker task to measure attentional control and a continuous performance task to measure sustained attention. Results One hundred nine children met all eligibility criteria for inclusion in a participant group. Regression models predicting performance on the attention tasks were similar for both sustained attention and attentional control. For both tasks, DLD was a significant predictor, and bilingualism was not. Measuring bilingualism continuously using parent-reported exposure did not alter results. Conclusions This study found no evidence of a "bilingual cognitive advantage" on 2 types of attention among sequential Spanish-English bilingual children but also found a negative effect of DLD that was consistent across both types of attention and both bilingual and monolingual children. Results are consistent with the broader literature on subtle nonlinguistic deficits in children with DLD and suggest these deficits are minimally affected by diverse linguistic experience.

1764. The Gut: A Veiled Reservoir for Multidrug-resistant Organisms (MDROs) Below the Tip of the Iceberg

Background

Clinical culture results are sometimes used to estimate the burden of multidrug-resistant organisms (MDROs) in hospitals. The association between positive clinical culture results and prevalence of MDROs in the gut is incompletely understood.

Methods

Rectal swab or stool samples were collected daily from adult medical intensive care unit (MICU) patients and cultured for target MDROs using selective media between January 2017 and January 2018 at Rush University Medical Center, a 676-bed tertiary-care center in Chicago. Resistance mechanisms were confirmed by phenotypic methods and/or polymerase chain reaction. Clinical culture results during MICU stay were extracted from the hospital information system. Target MDROs included vancomycin-resistant Enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL), carbapenem-resistant Pseudomonas aeruginosa (CRPA) and carbapenem-resistant Acinetobacter baumannii (CRAB). Patients with either a study or clinical culture positive for a target MDRO were analyzed.

Results

We collected 5,086 study samples from 1,661 unique admissions (1,419 patients) and included here data from 413 unique admissions (397 patients) with completed microbiologic analysis. Median (IQR) patient age was 65 (51–75) years and length of MICU stay was 3 (3–4) days. A total of 156 (37.8%) patients had a target MDRO detected from a study sample at any point; 57 (36.5%) patients had >1 MDRO detected. Overall prevalence of these MDROs was found to be 22.5% VRE, 6.5% CRE, 19.8% ESBL, 4.4% CRPA, and 0.7% CRAB. New MDRO acquisition was observed in 58 (14.6%) patients (figure). Once a target MDRO was detected in a study sample, 82.2% of subsequent study samples were positive for that MDRO. Only 13 (5.8%) patients had a positive clinical culture for any target MDRO during their MICU stay (table).

Conclusion

Clinical cultures capture only the tip of the resistance iceberg and alone are insufficient to guide MDRO-targeted prevention strategies. Universal infection prevention measures are an alternative that may be preferred in settings where overall prevalence of MDROs is moderate or high and patients may be colonized with >1 MDRO.

Disclosures

All authors: No reported disclosures.

Randomized Controlled Trial of Lifestyle Walking for African American Women: Blood Pressure Outcomes

The aim of this study was to test the effects of a lifestyle physical activity intervention (group meetings alone vs supplemented by personal or automated calls) on changes in systolic/diastolic blood pressures from baseline to 24 and 48 weeks among African American women. This was a randomized controlled trial with intervention conditions randomly assigned across 6 community health care sites. Participants were 288 sedentary African American women without major signs/symptoms of cardiovascular disease. Each intervention had 6 group meetings over 48 weeks, with 1 of 3 options between meetings: (1) no calls, (2) personal motivational calls, or (3) automated motivational calls. Blood pressures were taken at baseline, 24 weeks, and 48 weeks. Separate analyses were conducted using blood pressure classifications from the 2003 and 2017 high blood pressure guidelines. Average blood pressures decreased approximately 3 mm Hg for systolic and 2 mm Hg for diastolic from baseline to 48 weeks, with no differences between conditions. For both 2003 and 2017 blood pressure classifications, the risk ratio (odds of moving to a lower classification) was 1.44 for each assessment (P < .001). This lifestyle walking intervention appears beneficial in lowering blood pressure across blood pressure classifications in midlife African American women.

Chronotype, social jet lag, sleep debt and food timing in inflammatory bowel disease

The preference of the sleep/wake cycle can be grouped into categories or chronotypes. Inflammatory bowel disease (IBD) has been linked to poor sleep quality which correlates with disease severity. Social jet lag (SJL) is the difference between sleep timing on work and free days and is a marker for circadian misalignment which has been linked to increased inflammation. We investigated whether chronotype, SJL, sleep debt (SD), and food timing were associated with an IBD specific complications and a lower quality of life. Overall, 191 subjects (115 IBD subjects and 76 healthy controls (HC)) completed the Pittsburgh Sleep Quality Index (PSQI), Morningness-Eveningness Questionnaire (MEQ), Munich ChronoType Questionnaire (MCTQ), Short Inflammatory Bowel Disease Questionnaire (SIBDQ), and a structured Food Timing Questionnaire. Later chronotype (by MEQ) was associated with a worse SIBDQ (r = -0.209; P < 0.05). SJL was increased in IBD at 1.32 h ± 1.03 vs. 1.05 h ± 0.97 in HC, P < 0.05, when adjusted for age. SJL (>2 h) was present in 40% of severe/complicated Crohn's patients (fistulizing or structuring Crohn's or history of Crohn's related surgery) compared to only 16% of uncomplicated Crohn's patients (P < 0.05). Sleep debt was increased in IBD subjects compared to HC at 21.90 m ± 25.37 vs. 11.49 m ± 13.58, P < 0.05. IBD subjects with inconsistent breakfast or dinner times had lower SIBDQ scores (4.78 ± 1.28 vs. 5.49 ± 1.02, P < 0.05; 4.95 ± 0.31 vs. 5.42 ± 0.32, P < 0.05 respectively). In summary, later chronotype, and markers of circadian misalignment (social jet lag, sleep debt, and inconsistent meal timing) were associated with IBD disease specific complications and/or lower quality of life.

Gut Microbiota and Clinical Features Distinguish Colonization With Klebsiella pneumoniae Carbapenemase-Producing Klebsiella pneumoniae at the Time of Admission to a Long-term Acute Care Hospital

Background

Identification of gut microbiota features associated with antibiotic-resistant bacterial colonization may reveal new infection prevention targets.

Methods

We conducted a matched, case–control study of long-term acute care hospital (LTACH) patients to identify gut microbiota and clinical features associated with colonization by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp), an urgent antibiotic resistance threat. Fecal or rectal swab specimens were collected and tested for KPC-Kp; 16S rRNA gene-based sequencing was performed. Comparisons were made between cases and controls in calibration and validation subsamples using microbiota similarity indices, logistic regression, and unit-weighted predictive models.

Results

Case (n = 32) and control (n = 99) patients had distinct fecal microbiota communities, but neither microbiota diversity nor inherent clustering into community types distinguished case and control specimens. Comparison of differentially abundant operational taxonomic units (OTUs) revealed 1 OTU associated with case status in both calibration (n = 51) and validation (n = 80) subsamples that matched the canonical KPC-Kp strain ST258. Permutation analysis using the presence or absence of OTUs and hierarchical logistic regression identified 2 OTUs (belonging to genus Desulfovibrio and family Ruminococcaceae) associated with KPC-Kp colonization. Among clinical variables, the presence of a decubitus ulcer alone was independently and consistently associated with case status. Combining the presence of the OTUs Desulfovibrio and Ruminococcaceae with decubitus ulcer increased the likelihood of KPC-Kp colonization to >38% in a unit-weighted predictive model.

Conclusions

We identified microbiota and clinical features that distinguished KPC-Kp gut colonization in LTACH patients, a population particularly susceptible to KPC-Kp infection. These features may warrant further investigation as markers of risk for KPC-Kp colonization.

African-American Women's Perceived Risk for Cardiovascular Disease versus Framingham Risk

Cardiovascular disease (CVD) is the leading cause of death among African-American women in the United States. Accurate CVD risk perception may motivate these women to participate in health-promoting behaviors; however, perceived risk may not align with objective CVD risk. Our objective was to examine CVD risk perception, risk factors, and objective estimated risk (based on Framingham scores). This was a secondary data analysis of data collected from a 12-month lifestyle PA intervention conducted with 281 African-American women. Subjective perceived CVD risk was measured with two questions; CVD risks were examined via health assessment and self-questionnaire; and objective estimated CVD risk was calculated using the Framingham Risk score. Despite having several objective risk factors for CVD development, most participants perceived their CVD risk as low, and their Framingham scores were low. The Framingham Risk score may not be the best predictor of CVD risk for African-American women.

Behavioral Pain Intervention for Hospice and Palliative Care Patients: An Integrative Review

Despite the advances in pain management, achieving optimal pain control in hospice and palliative care is challenging. Patient/caregiver's lack of pain management knowledge, poor pain reporting, and poor adherence to pain management regimens are all associated with inadequate pain control. The purpose of this integrated review is to examine behavioral interventions designed for patients and caregivers to improve pain control in hospice and palliative care settings. Ten studies were identified through a database search. Seven of the 10 studies found significant improvement in at least 1 pain marker. Of the 7 studies that looked at changes in pain knowledge, 5 had significant improvements in at least 1 knowledge subscale. The 2 studies that looked at adherence to pain management found significant improvements. One limitation of the reviewed studies was that the delivery of them would not be efficient across all health-care settings, and, as a consequence, more technologically sophisticated delivery methods are needed. Therefore, while it is clear from the review that effective pain management interventions have been developed for hospice and palliative care patients, it is also clear that future research needs to focus on providing these same interventions through a more technologically sophisticated delivery method.

Effects of a Staff Training Intervention on Seclusion Rates on an Adult Inpatient Psychiatric Unit

The current article presents the effects of a 90-minute staff training intervention aimed at reducing inpatient psychiatric seclusion rates through strengthened staff commitment to seclusion alternatives and improved de-escalation skills. The intervention occurred at an 18-bed adult inpatient psychiatric unit whose seclusion rates in 2015 were seven times the national average. Although the project's primary outcome compared patient seclusion rates before and after the intervention, anonymous staff surveys measured several secondary outcomes. Seclusion rates were reduced from a 6-month pre-intervention average of 2.95 seclusion hours per 1,000 patient hours to a 6-month post-intervention average of 0.29 seclusion hours per 1,000 patient hours, a 90.2% reduction. Completed staff surveys showed significant staff knowledge gains, non-significant changes in staff attitudes about seclusion, non-significant changes in staff de-escalation skill confidence, and use of the new resource sheet by only 17% of staff. The key study implication is that time-limited, focused staff training interventions can have a measurable impact on reducing inpatient seclusion rates. [Journal of Psychosocial Nursing and Mental Health Services, 56(6), 23-30.].

Abstract P2-09-30: A gene expression signature that predicts for trastuzumab response in HER2+ breast cancer

Background: Approximately 15-20% of breast cancers overexpress HER2. These patients are eligible for trastuzumab in combination with chemotherapy. However, some patients are extreme responders to single agent trastuzumab and we wanted to identify differences in cancer gene expression that could predict response to single agent trastuzumab.

Methods: We performed paired-end RNAseq on an isogenic cellular model of trastuzumab sensitivity and resistance. We reasoned that the isogenic nature of the cellular clones used in this study would enrich for differentially-expressed genes (DEGs) that were associated with response to single-agent trastuzumab. DEGs where chosen based upon either i) large fold changes in resistant vs. sensitive clones, ii) high frequency in human HER2+ breast cancers, or iii) were found to be enriched with other DEGs in signaling pathways selected by Ingenuity Pathway Analysis (IPA). DEGs were further scrutinized based upon associations with overall survival (OS) in HER2+ human breast cancers. The resulting genes were validated using qPCR and in several independent sample sets containing gene expression profiles of human breast cancers.

Results: Discovery: RNAseq yielded 3,241 statistically-significant DEGs. We used two independent filtering pipelines to obtain 175 DEGs. Ingenuity Pathway Analysis found signaling pathways associated with eukaryotic initiation factor, lysine specific demethylase 5B, and estrogen receptor alpha to be enriched in DEGs associated with trastuzumab resistance. Of these DEGs, six genes correlated with a statistically significant change in OS in the training dataset, and were validated by qPCR in the cell lines used for the analysis. We further determined that the six-gene signature was a negative predictor of overall survival in HER2+ breast cancer patients whose cancers carried at least one DEG. Validation: Using independent cohorts from TCGA and the website KMplot.com, we validated the predictive power of the six-gene signature. Of the 47 HER2+ patients from TCGA, eight patients carried two more DEGs, while 39 carried ≤ 1 DEG. Although the numbers are small, of the 8 patients followed for four or more years, only one patient was alive as compared with 7 out of 39 patients without the signature. Similarly, Kaplan Meier analysis of gene expression data from KMplot.com revealed that only 1 out of 23 patients (4.3%) who carried high mean expression of the six-gene signature were free of distant metastases after 87 months, compared to 4 out of 43 patients (9.3%) from the cohort carrying low mean expression of the six-gene signature. In both validation cohorts, the six DEG signature was not predictive in HER2-negative breast cancers.

Discussion: Patients whose tumors lack this gene expression signature are more likely to experience a favorable response to trastuzumab therapy. This signature requires validation in a clinical cohort treated with trastuzumab monotherapy.

Citation Format: Abukhdeir AM, Najor MS, Turturro SB, Armstrong AR, McDonald A, Fogg L, Cobleigh MA. A gene expression signature that predicts for trastuzumab response in HER2+ breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-30.

Polyethylene Glycol-3350 (Miralax®)+1.9-L sports drink (Gatorade®)+2 tablets of bisacodyl results in inferior bowel preparation for colonoscopy compared with Polyethylene Glycol-Ascorbic Acid (MoviPrep®)

BACKGROUND/AIMS

Polyethylene glycol (PEG)-3350, approved by Food and Drug Administration (FDA) only for constipation, combined with 1.9 L of sports drink (SD) (GatoradeR) and bisacodyl (B) is commonly used in outpatient practice for bowel preparation due to cited patient satisfaction and tolerability of this specific regimen. We aim to compare PEG-3350 (MiralaxR) with PEG-AA-based (MoviPrepR) in terms of efficacy, patient satisfaction, and the effects of these two regimen on serum electrolytes.

MATERIALS AND METHODS

This study is a prospective, single-blinded, block randomized trial comparing single-dose PEG-3350+SD+B to split-dose 2-L PEG-AA in the outpatient endoscopy unit in patients undergoing colonoscopy. Basic metabolic profiles were checked on the day of randomization and on the day of procedure. Patients completed a survey on the day of procedure. Bowel preparation quality was assessed using the Boston Bowel Preparation Scale (BBPS) by two endoscopists and a nurse present during the procedure.

RESULTS

We randomized 150 patients (74 PEG-3350+SD+B and 76 PEG-AA). The PEG-AA group had significantly higher BBPS scores in the right colon by Endoscopist 1, Nurse, and Endoscopist 2 (p 0.005, <0.000, 0.001) and in the left and transverse colon by Nurse and Endoscopist 2 (p 0.004, 0.26, 0.000, 0.006). There was no statistically significant difference in patient satisfaction or change in serum electrolytes between the two groups.

CONCLUSION

Use of single-dose PEG-3350+SD+B results in inferior bowel preparation for colonoscopy compared with split-dose PEGAA and does not provide any advantage in regards to patient satisfaction. We therefore recommend discontinuing the use of PEG 3350 for bowel preparation.

Randomized Clinical Trial of the Women's Lifestyle Physical Activity Program for African-American Women: 24- and 48-Week Outcomes

PURPOSE

To compare the effects of a physical activity (PA) intervention of group meetings versus group meetings supplemented by personal calls or automated calls on the adoption and maintenance of PA and on weight stability among African-American women.

DESIGN

Randomized clinical trial with three conditions randomly assigned across six sites.

SETTING

Health settings in predominately African-American communities.

SUBJECTS

There were 288 women, aged 40 to 65, without major signs/symptoms of pulmonary/cardiovascular disease.

INTERVENTION

Six group meetings delivered over 48 weeks with either 11 personal motivational calls, 11 automated motivational messages, or no calls between meetings.

MEASURES

Measures included PA (questionnaires, accelerometer, aerobic fitness), weight, and body composition at baseline, 24 weeks, and 48 weeks.

ANALYSIS

Analysis of variance and mixed models.

RESULTS

Retention was 90% at 48 weeks. Adherence to PA increased significantly (p < .001) for questionnaire (d = .56, 128 min/wk), accelerometer (d = .37, 830 steps/d), and aerobic fitness (d = .41, 7 steps/2 min) at 24 weeks and was maintained at 48 weeks (p < .001), with no differences across conditions. Weight and body composition showed no significant changes over the course of the study.

CONCLUSION

Group meetings are a powerful intervention for increasing PA and preventing weight gain and may not need to be supplemented with telephone calls, which add costs and complexity.

Outcome of assisted reproduction in women with congenital uterine anomalies: a prospective observational study

OBJECTIVES

To assess the prevalence of congenital uterine anomalies, including arcuate uterus, and their effect on reproductive outcome in subfertile women undergoing assisted reproduction.

METHODS

Consecutive women referred for subfertility between May 2009 and November 2015 who underwent assisted reproduction were included in the study. As part of the initial assessment, each woman underwent three-dimensional transvaginal sonography. Uterine morphology was classified using the modified American Fertility Society (AFS) classification of congenital uterine anomalies proposed by Salim et al. If the external contour of the uterus was uniformly convex or had an indentation of < 10 mm, but there was a cavity indentation, it was defined as arcuate or septate. Arcuate uterus was further defined as the presence of a concave fundal indentation with a central point of indentation at an obtuse angle. Subseptate uterus was defined as the presence of a septum, not extending to the cervix, with the central point of the septum at an acute angle; if the septum extended to the internal cervical os, the uterus was defined as septate. Reproductive outcomes, including live birth, clinical pregnancy and preterm birth, were compared between women with a normal uterus and those with a congenital uterine anomaly. Subgroup analysis by type of uterine morphology and logistic regression analysis adjusted for age, body mass index, levels of anti-Müllerian hormone, antral follicle count and number and day of embryo transfer were performed.

RESULTS

A total of 2375 women were included in the study, of whom 1943 (81.8%) had a normal uterus and 432 (18.2%) had a congenital uterine anomaly. The most common anomalies were arcuate (n = 387 (16.3%)) and subseptate (n = 16 (0.7%)) uterus. The rate of live birth was similar between women with a uterine anomaly and those with a normal uterus (35% vs 37%; P = 0.47). The rates of clinical pregnancy, mode of delivery and sex of the newborn were also similar between the two groups. Preterm birth before 37 weeks' gestation was more common in women with uterine anomalies than in controls (22% vs 14%, respectively; P = 0.03). Subgroup analysis by type of anomaly showed no difference in the incidence of live birth and clinical pregnancy for women with an arcuate uterus, but indicated worse pregnancy outcome in women with other major anomalies (P = 0.042 and 0.048, respectively).

CONCLUSIONS

Congenital uterine anomalies as a whole, when defined using the modified AFS classification, do not affect clinical pregnancy or live-birth rates in women following assisted reproduction, but do increase the incidence of preterm birth. The presence of uterine abnormalities more severe than arcuate uterus significantly worsens all pregnancy outcomes. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.